Friday, December 31, 2010

Meet the Twiblings - NYTimes.com: "Is your goal to have the experience of being pregnant or is your goal to have the best chance of having a healthy baby?” he asked. “If you really want a healthy baby, get a surrogate and an egg donor.” In that instant, I made up my mind. Of course that was my goal — and compared with that goal, all other desires seemed not only secondary, but also trivial, even narcissistic. I began researching surrogacy and egg donation — corresponding with gestational carriers on surrogacy Web sites and talking to agencies.

Very touching story - please read this ! I love the fact that the parents have been so open and generous with their feelings and the facts - this is so refreshing. I wish more infertile couples would do this, rather then try to hide their identity ! Why should you be ashamed of the fact that you needed medical assistance to have a baby ? Does this make you less of a mother ? Unless infertile couples are willing to stand up and tell their stories ( and how dramatic some of these stories are !) , society's attitudes towards infertility will never change !

Mobisante is one example of a company that is building a specialized medical device on top of a smartphone. It has developed software that allows a Windows Mobile smartphone to connect to an ultrasound probe via USB, in effect turning it into a fully functional, portable ultrasound system. It uses the computing power of the phone to process and render images, and the built-in cellular or Wi-Fi radios to transmit data. The result is a system that is extremely portable, connected, and affordable, which brings ultrasound imaging within reach of more than 70% of the population that doesn’t have access to it today.

This is a fascinating example of how clever companies are using consumer technology to make healthcare much more affordable and available. This would be perfect for developing countries like India, and would make sophisticated medical imaging accessible in every village ! The tragedy is that it will never be possible to use this innovation in India. The PNDT Law would not allow it !

Thursday, December 30, 2010

Infertile couples are often confused whom they should visit when they need medical assistance. Even though infertility always affects a couple , it's usually the woman who takes the initiative in seeking medical care . Most will bypass their family physician , but are unsure whether to go to a gynecologist or an infertility specialist. Both options have advantages and disadvantages , and it's worth examining these.

The gynecologist is a logical first choice. Most women have a long-standing relationship with their gynecologist , and are comfortable with him. Since gynecologists are specialists in tackling women's health problems , most can competently diagnose the cause of infertility ; and provide basic medical treatment. They are usually quite conservative; and would be the first choice for simple problems . However , they are often poorly equipped to deal with complex infertility problems.

Since a man with a hammer only sees nails, they will often subject the patient to unnecessary surgical procedures , such as a laparoscopy; or perform intrauterine inseminations for men with low sperm counts , simply because they do not have anything else to offer. They are often extremely poor at handling male infertility problems , and will usually refer these to their friendly urologist. This often means that care gets fragmented; and ends up of being poor quality.

Most gynecologists are also not aggressive enough when dealing with older women. Since most of their women are fertile, they often forget to remember the impact which aging has on the ovarian reserve of infertile women.

Also since they rarely have a special interest in treating infertility , waiting rooms are often quite infertile-patient unfriendly. There are often full of expectant mothers , and this can cause unnecessary emotional distress. Also some of them are not compassionate or empathetic enough when dealing with the impact which infertility has on the woman's psyche.

Infertility specialists would be the first choice, if you have a complex problem. Not only are they experts at dealing with infertility they have a lot of experience; and are armed with the advanced reproductive technology to solve most problems. However they are often quite expensive ; and some of them will often resort to unnecessary , complex costly treatment, even to tackle simple problems.

This means the patient has to choose between the risk of wasted time with the gynecologist, versus overtreatment with the infertility specialist. Since the infertile couple doesn't know how simple or complex their medical problem is , this often leaves them in a quandary.

What we do in our clinic ? If I am the first doctor the infertile couple is seeing, I will complete the workup for them , so we have an idea as to what the reason for the infertility is. This takes about 7 days and costs about US $ 200 only. If it's a simple problem , we will suggest that they find a gynecologist for their treatment. This allows us to concentrate on infertile couples who have complex problems , so that we can provide them with a higher quality of service, without diluting our focus.

In the best of all possible worlds , gynecologists with take care of the simple problems ; and if they have failed to achieve a pregnancy within 6 months , they would refer these patients onto an infertility specialist. Unfortunately, since most doctors have a proprietary attitude towards their patients , they are often reluctant to refer these patients to infertility specialists , because they do not want to lose them. This often means that they waste the patient's time , money and energy in pursuing ineffective treatments.

One useful tip is to create a clear plan of action with a well defined timeframe in partnership with your doctor , so you have a clear sense of what your treatment options are. This way, you retain control of your medical treatments as well as your life so you have peace of mind you did your best.

Want to make sure you are on the right track ? Please send me your medical details by filling in the Free Second Opinion Form and I'll be happy to help !

We have been married for 9 yrs now! Since we got married early, we decided not to have a baby for 5 yrs.We lived merrily for 5 yrs of our marriage travelling to & fro from India & US.After 5 yrs suddenly we decide,we want a baby! That''s when hell struck in paradise!We learnt in India that I have PCOS & I wasn't ovulating properly.We just kept trying to rectify my problem with lot of medication which my husband calls it poison tablets as they were affecting my body.We kept trying naturally but no luck.In the mean while we travelled back to the US only to find out my husband has low morphology! The doctor told us we might not get pregnant naturally.More hell struck in paradise! It took us a while to accept the fact & then we went for an IUI,which obviously was a failure.We were devastated.Doctor suggested us to go for an IVF,but we didn't have money specially to do it in the US.It was going to cost us a fortune.We had the best doctor & he was very patient with us.He gave us lot of time to think & rethink,& kept treating us with different combinations of medicines with a few more IUI's,all of which were unsuccessful.While we were at it,trying our best,leaving no leaf unturned,taking treatments,medicines,tests,praying to God,so many days,months,years passed by.It was nerve breaking for us!

We were struggling & struggling & others around us were just popping out babies . On a lighter note, my husband with an unique sense of humour calls these couples production engineers or pop up toasters!! kept supporting me through the battle field. In the mean while in the year 2009 & 2010 i had 2 chemical pregnancies but obviously miscarried,but on the brighter side I had conceived naturally both the times.It was miraculously surprising for us! By now I had started understanding that come what may,how you plan your life,your future,your decisions;God has some other plans for you.He has already decided your whole life.He is the controller & not us.We are merely his puppets.I perceived that God will definitely fulfill my wish but in his time & not when i want it,& whatever it will be,it will be for my good.

So after a lot of convincing by my doctor here to do IVF we finally decide to go for it but not in US,in India as it would be cheaper there.It was another stressful decision for me as doing IVF in India meant seeing another doctor.As I went to my doctor here for 3.5 yrs I was so comfortable with him & so attached that I didn't wish to go to India.My friend referred me to Dr Malpani & told me to completely rely on him.Initially I was reluctant for he was in Colaba,which meant 2 hours of travel for me one way from Vile Parle.But still i finally decided to see him.I was so very nervous in our very first meeting but Dr Aniruddha made me feel so comfortable as if we weren't meeting for the first time.He was very friendly & sweet with us.He saw all our reports & suggested we do ICSI instead of IVF.We went ahead & started our treatment.I felt equally comfortable meeting Dr Anjali & interacting with her & the whole staff.The whole procedure was fairly easy & less stressful than I thought as I was vacationing in India & the Doctors made it easy too.Soon the procedure was over with.Three Grade A embryos were transferred & now was the nerve breaking,head banging,throat slitting 2 weeks wait..It was the most horrible period of my life as I was back in US to be all alone to wait for the news.

And FINALLY it happened for us!!!!! after 4 yrs of trying & waiting,with 5 unsuccessful IUI's & 2 miscarriages, YES WE WERE PREGNANT! After all our endeavors & endurance & by Gods grace we are finally pregnant.We were destined to do the procedure with the Malpanis.For us they are truly God sent Angels.They are too good & best at what they are doing...I call it a Noble Deed!! God Bless them always.Thank you very very much.

The book is targetted towards infertile women living in the US, and is written in the currently fashionable "chick-lit" style. It's amusingly written; and is a breath of fresh air , if you are the sort of person who finds a sense of humour helps you cope better with infertility.

The book has lots of Top-10 lists, and here's their list of Top Ten Tips for Facing Infertility.

# 10 Tips for Facing Infertility1. Keep reminding yourself that you are not alone.2. Realize that dealing with infertility is an all-consuming process.3. Stay calm.4. Remind yourself you are not a failure if a procedure doesn't work.5. Have a sense of humor about this - even if it doesn't seem at all funnyright now.6. Do your research. Then do some more.7. Listen to your body and your inner self. If you really listen you willlearn those two are rarely wrong.8. Don't rule anything out - from antibiotics to acupuncture and fromyoga headstands to standing on your head during sex.9. Find the right doctor.10.Don't get angry at your partner for not nurturing you - he is hurtingand confused, too.

Here are my comments about this list.

1. Keep reminding yourself that you are not alone.

One of the major problems with infertility is the social and emotional isolation it causes. It seems that everyone around you is having babies and you are the only one who cannot have them ! Moreover, there is little social support , and people can be thoughtless and unkind. However, remember that you are in this together with your partner - and you can love and support each other. Millions of other couples are also fighting the same battle - and you can support each other.

2. Realize that dealing with infertility is an all-consuming process.

Many infertile couples are amazed when they find how obsessed they become with tracking their fertility - and how their desire to have a baby seems to become the central focus of their life.

3. Stay calm.

This can be hard to do , especially at certain times : for example, when your period had just started; your friend has just told you she's pregnant again; the latest treatment which seemed to be going so well has failed; and it seems that your partner does not care or understand. Don't make a bad situation worse by losing your calm. If you can weather this, you will emerge a much stronger and better person !

4. Remind yourself you are not a failure if a procedure doesn't work.

The failure of a procedure does NOT mean you are a failure ! When the embryos transferred during an IVF cycle fail to implant, many women feel that their uterus is defective and has "rejected" the embryos. Remember that Nature is not efficient at making babies - and the odds are always going to be against you in each month, so you need to be patient. Have realistic expectations, and treat this as a war , not just a battle. Even if the procedure fails, you have peace of mind you tried your best - and failed procedures also provide the doctor with useful information which he can use to fine-tune your next treatment cycle, bringing you closer to your goal.

5. Have a sense of humor about this - even if it doesn't seem at all funny right now.

A sense of humour is often the only thing which help you keep your sanity ! Hang on to this - it will help you cope with whatever trials and tribulations you may have to deal with !

6. Do your research. Then do some more.

You can never know too much. While the endpoint is not to become an IVF specialist ( though you will find that you often know much more about infertility than your GP or family physician, many of whom are quite clueless about infertility), you need to become an expert on your problem, so you have peace of mind you did your best, and didn't leave any stone unturned.

7. Listen to your body and your inner self. If you really listen you will learn - those two are rarely wrong.

This is good advise, whether you are infertile or not ! However, be careful not to fall into the trap of listening only to your body - and not listening to your doctor ! Find the right balance between the inner wisdom of the body and the outer wisdom of medical science.

8. Don't rule anything out - from antibiotics to acupuncture and from yoga headstands to standing on your head during sex.

Keeping an open mind is a good idea - but it shouldn't be so open that everything in it falls out either ! It's fine to use yourself as a guinea pig, if that's what you want to do. Take an objective approach, and treat your experiences as a scientific experiment ( on yourself). Document all your results, so that you can learn from them.

9. Find the right doctor.

While everyone knows how important it is to find Dr Right, it can be extremely hard to do this in real life ! Often you are trapped by the healthcare system you find yourself in - or you don't know how to judge your doctor's competence and abilities.

10.Don't get angry at your partner for not nurturing you - he is hurting and confused, too.

Don't make a bad situation worse by using your partner as a punching bag. Being infertile is bad enough - but as long as you can love and support each other, you'll find it much easier to deal with. Love divides the misery, and any couple who can weather the crisis of infertility will find that their marriage is much more resilient than the ordinary marriage. It is true that all Men are from Mars , not just your husband ! The sooner you accept this, the easier it will be for both of you. From his point of view, his priority is to work so that he can earn the money you need to be able to afford infertility treatment ! Providing emotional support comes a distant second in his brain, so please be charitable !

Want to make sure you are on the right track ? Please send me your medical details by filling in the Free Second Opinion Form and I'll be happy to help !

Monday, December 27, 2010

Mullerian agenesis refers to a condition in a woman where the uterus is absent from birth. This is a birth defect , but is only diagnosed when she fails to get her periods on attaining puberty . This is called primary amenorrhea.

Normally, the uterus develops in uterus from embryological structures called mullerian ducts . When these fail to develop in utero, the baby girl is born without a uterus . This causes no symptoms or signs in the child, who looks and behaves like a completely normal girl. It’s only when the periods do not come that this diagnosis is made. This can bea rude shock to an emotionally vulnerable teenager, and can cause enormous frustration and resentment.

This defect occurs usually because of a random birth defect – not because of anything anyone did or did not do, so please do not blame yourself – or your mother !

This condition is also called MRKH or Mayer-Rokitansky-Küster-Hauser Syndrome, named after August Franz Joseph Karl Mayer, Carl Freiherr von Rokitansky, Hermann Küster, and G.A.Hauser.

Because girls with Mullerian agenesis are hormonally normal, they will develop all the secondary sexual characteristics of puberty, including thelarche ( breast development) and adrenarche ( pubic hair growth), but they will not have periods. The chromosomes are normal - 46,XX.Typically, the vagina is shortened and intercourse will be difficult and painful. Medical examination supported by gynecologic ultrasonography demonstrates a complete or partial absence of the cervix, uterus, and vagina.

Since there is no uterus, women with MRKH cannot carry a pregnancy. However, it is possible for these women to have genetic offspring by in vitro fertilisation (IVF) and surrogacy. Uterine transplantation is currently not a treatment that can be offered.

Women with MRKH typically discover the condition when, during puberty years, the menstrual cycle does not start. Some women find out earlier through surgeries for other conditions, such as a hernia.

Although there are treatments to increase the comfort in sexual intercourse, there are none to let the woman herself become pregnant. Some women also choose to adopt.

It may be necessary to use vaginal dilators or surgery to develop a functioning vagina to allow for satisfactory sexual intercourse. A number of surgical approaches have been used. In the McIndoe procedure a skin graft is applied to form an artificial vagina. After the surgery, dilators are still necessary to prevent vaginal stenosis. The Vecchietti procedure is a laparoscopic procedure that has been shown to result in a vagina that is comparable to a normal vagina in patients with Mullerian agenesis.

Emotional help is available in various support groups across the internet. With the internet and these support groups, women with MRKH feel less like they do not belong, and are able to deal with the syndrome with more confidence and security. Useful websites include: www.mrkh.org; and www.mrkhstories.com

Sunday, December 26, 2010

The most common cause of azoospermia in India was previously smallpox. This infection injured the epididymis, leading to ductal obstruction. Fortunately, this particular disease is now of historical importance only, as it has been wiped out. Tuberculosis also harms the epididymis, causing azoospermia. Nevertheless, making the correct medical diagnosis of tuberculous epididymitis can be quite difficult, since it is often a silent as well as indolent disease. Gonorrhea, chlamydia, syphilis along with other STDs ( sexually transmitted diseases) might also create chaos with the man's genital system; leading to irreparable injury to its epithelium (inner lining).

Mumps may also cause orchitis (inflammation of the testis) - particularly when this impacts younger males. This may result in significant harm to the testes, creating testicular failure if it damages both ovaries. However, do remember that not every boy who gets mumps will have sperm problems as an adult.

How about other genital tract infections? Many patients ( and their doctors!) worry when the semen analysis report shows pus cells or WBCs ( white blood cells) . This condition is called pyospermia or leucocytospermia. Do remember that a few pus cells in the semen are quite normal and this finding does not mean you have a semen infection. Also, fertile men will often have round cells in their semen. These are not pus cells, but are sperm precursor cells ( spermatocytes). However, many labs are not capable of differentiating between pus cells and sperm precursor cells. They report these round cells as pus cells and doctors will then start antibiotic treatment to "treat" this infection. This is a complete waste of time and money!

Many doctors will perform a semen culture as well when the semen sample contains numerous pus cells. If the examination is positive, then therapy with antibiotics will be implemented. However, many of the organisms grown in these culture reports are not really pathogenic organisms at all, but just normal commensals which colonise the genital tract and are found in normal fertile men as well. The connection between the existence of bacteria inside the semen and male infertility continues to be cloudy. Do the bacteria actually result in the infertility? Will dealing with the infection assist in improving fertility? Many more questions than answers, once again! In my opinion, treating most of these "abnormal reports" does not help to improve the man's fertility at all.

Saturday, December 25, 2010

One of the major decisions infertile patients have to make is - How to pick a really good IVF clinic? The majority of IVF treatment centers appear to be identical on paper, and their websites are quite similar (because some unethical doctors will unashamedly copy and paste content from our website!). Many have happy patients - and most IVF specialists talk the identical talk - all of them quote high success rates and claim they are the finest! Exactly how is a poor patient supposed to separate the wheat from the chaff and assure himself that the IVF clinic he's going to is efficient? After all, while it is easy for patients to evaluate a doctor's bedside manner, it's difficult for them to make a call concerning his medical and technical proficiency.

Simply because the IVF cycle fails doesn't mean that the doctor was bad or the medical clinic was incompetent. After all, IVF carries a restricted rate of success, and only about 20% of embryos implant to become a baby. An unsuccessful IVF might just imply that the embryos failed to implant for unexplained biological causes - and isn't immediately a cause to switch your IVF clinic!

One extremely important tangible end point that all patients may use to evaluate the particular clinical proficiency of their own IVF clinic is to demand that the clinic give them photographic documentation of their own embryos. All superior treatment centers do it regularly, for a lot of factors. It records the high quality of medical attention delivered - after all, the proven fact that the clinic made embryos implies that they are skilled at super ovulation, egg retrieval and fertilization - and high quality clinics are usually proud to show their expertise! Creating embryos in vitro depends on elements that are primarily in the clinic's control - while the result of the embryo transfer, sadly, is not. This record additionally signifies that they have confidence about their clinical expertise and have nothing to conceal. This openness is extremely patient-empowering! Equally importantly, these photographs are extremely useful in circumstances when you need to get a second opinion, or to proceed to another IVF clinic.

In case your IVF clinic doesn't regularly give you with a written brief summary of your treatment cycle and photos of your embryos, then this is a warning sign! And if they refuse to share these with you even after you ask them to, this is a major black mark against them - and is a powerful indication that you need to search for another clinic. After all, why should a good clinic conceal anything?

Malpani Infertility Clinic offers IVF ( In Vitro Fertilization )Treatment to infertile couples from all over the world. Like most infertile couples, you know that IVF can maximise your chances of getting pregnant. Malpani Infertility Clinic, IVF treatment Center in India

Friday, December 24, 2010

" Patients appear to be the problem in modern high-tech health care: they areuninformed, anxious, noncompliant folk with unhealthy lifestyles. They de-mand drugs advertised by celebrities on television, insist on unnecessary butexpensive computer tomography (CT) and magnetic resonance imaging (MRI)scans, and may eventually turn into plaintiffs. Patients’ lack of health literacyand the resulting costs and harms have received much attention."

Please read this very thought-provoking article called The Century of the Patient, which talks about how we can help patients to become better informed !

Often an absolutely fertile male with a completely normal sperm count might not be able to ejaculate in his wife's vagina. Because he cannot make love he cannot make babies. Many males cannot produce an erection (erectile dysfunction, ED or impotence); while others can't attain an erection which is hard enough to achieve intravaginal penetration or ejaculation within the vagina.

An older idea held that 80% of impotency issues were rooted in mental inhibition that could be treated with sex therapy and counseling. However modern day studies estimate that 50% result from physical causes which range from inadequate blood circulation to the penis, diabetes, neurologic defects, and hormonal complications.

How can a doctor suspect a physical problem? By asking a basic question - Do you have wet dreams? If males get nocturnal ejaculations (wet dreams) this means their penis works properly,, and that the issue is emotional.

Screening, consists of nocturnal penile tumescence (NPT) testing, that monitors for regular night-time erection strength; and calculating blood circulation through the arteries of the penis (using Doppler techniques). You can also do this test for yourself at home by using postage stamps!

Often the erectile dysfunction is situational. This means that while the man can masturbate, he just cannot get an erection while trying to have sex. This creates a lot of emotional discord and marital disharmony. The wife may feel that her husband is just not trying hard enough (pardon the pun!); or that he does not find her sexually attractive. Also, because ED destroys a man's self-esteem, both partners are very reluctant to discuss this or seek medical assistance. This just sets up a negative vicious cycle which makes matters worse. Either they just refuse to try; or every time they try, they fail, thus reinforcing the sense of inadequacy and incompetence. The man's mind starts playing games with him - and because he feels he is not going to be able to perform, this becomes a self-fulfilling prophecy. Failure to consummate the marriage is quite a common problem - but one few couples are willing to explicitly acknowledge.

The good news is that this is quite an easy problem to treat!

Treatment that may be recommended includes:

Medications which improve penile blood flow such as Viagra (sildenafil citrate) and Cialis (tadalafil citrate) to encourage an erection

Injections of papaverine as well as prostaglandins, (chemical substances that cause the blood vessels to dilate) could be self- injected into the penis under medical guidance These boost the blood circulation towards the penis, thus inducing an erection.

A medical implant or penile prosthesis to provide an artificial erection.

Microsurgery to plug leaks in the blood vessels of the penis, therefore avoiding the loss of turgidity from the erect penis.

The sperms may also be collected by masturbation and used for self-insemination or artificial insemination. This provides an extremely high success rate, since there is really no fertility problem as such for these patients.

We got married in November 2005. We felt the need to have our third member in the family at the end of the year 2007. Even after trying for six months we got no result.We contacted gynaecologist from one renowned hospital near our residence at Kolkata. After doing some routine blood test, hormone level test, USG etc. of wife, doctor opined that except two- three small size cysts (less than 30 mm in maximum dimension), which are harmless, everything is fine. We were told to try for another three months at some particular days of wife’s menstrual cycle.

After three months, in September 2008, we again contacted Doctor as there was no positive result. This time doctor prescribed Semen Analysis for husband. In Semen Analysis, sperm count was found to be nil. Doctor said that we have no other option but to take the help of donor sperm or donor embryo to have a baby.

After searching in the internet, we got address of Manipal Hospital, Bangalore. On visit in March 2009, Andrologist at Manipal Hospital prescribed a repeat Semen Analysis. The result was same as the previous one. He advised to undergo one micro-surgery of husband to detect the problem. He said after this micro-surgery, on the availability of healthy sperm, future course of action (IVF with sperm from husband or donor) would be decided.1st IVF CYCLE:In June 2009, the above micro-surgery was done at Manipal Hospital, Bangalore and it was found that husband is suffering from Absence of Bi-lateral Vas Deferens (ABLVD). 1st IVF cycle was done with few motile sperm taken from husband through TESA (Testicular Sperm Aspiration). Some sperms were cryo-preserved at infertility clinic of hospital itself for future use. Eggs were taken from wife after prescribed dose of hormonal injection for super-ovulation. Embryo quality was poor in this cycle. Out of two embryos fertilized in the process, one was transferred. But it did not get implanted and cycle failed.

2nd IVF CYCLE:In January 2010, 2nd IVF cycle was done at Manipal Hospital, Bangalore with husband’s sperm taken from preserved lot of earlier cycle. Eggs were taken from wife as in earlier cycle. This time the treatment protocol as well as dose of hormonal injection was different.Embryo quality was poor in this cycle. Out of three embryos fertilized in the process, one was transferred. But it did not get implanted and cycle failed.

Search for Alternative Clinic:After further searching in the internet, we got address of Malpani Infertility Clinic Pvt. Ltd., Mumbai. It was altogether a different experience.

The website of clinic is very informative, well designed and very user friendly. Basic knowhow of human infertility, various treatment procedure etc. are available there. Persons suffering from infertility can create their own account in the website for regular interaction with doctor. It is the clinic of doctor-duo Dr. Aniruddh Malpani & Dr. Anjali Malpani.

We submitted our query, stating all our previous medical history, to them.We were advised to do one blood test (AMH test) of wife, at designated diagnostic centre of Kolkata. As the test report was submitted it was promptly replied with a detailed plan of next IVF cycle at their clinic.

3rd IVF CYCLE:

In September 2010, 3rd IVF cycle was done at Malpani Infertility Clinic Pvt. Ltd., Mumbai with husband’s sperm taken through PESA. Eggs were taken from wife as in earlier cycles. This time the dose of hormonal injection was maximum.Cyst aspiration was done before ET (Embryo Transfer).Embryo quality was very good in this cycle. Four no. A-grade embryos were fertilized in this cycle out of which three nos. was transferred. Wife was advised to take some medicines and do the blood test after 15 days.Blood Test for pregnancy (β-HCG) was done 15 days after ET and it was positive.Now wife is three months pregnant and condition of fetus is healthy.Thus our dream of having our own baby fulfilled !!

Recently I witnessed an infertile couple who had over three heavy files bulging along with medical tests and reviews. They may have visited more than ten infertility experts who tried every single possible examination under the sun to attempt to discover what their issue was. The lady had been examined for antisperm antibodies, NK cells , hostile cervical mucus, tuberculosis, chlamydia, sperm DNA fragmentation… you name it, and she had had the examination done. Every single gynaecologist had repeated test after test, however every result had been normal. They were at their wit’s end. “Why can’t I get pregnant , doctor , if things are all normal ?” was her plaintive cry.

I was surprised about how little she had learned after going to numerous doctors. Rather than understanding from her experience, she was still asking the wrong question ! She expected me to order extra medical tests, or utilize some modern device in order to probe her insides and pinpoint the elusive issue.

I needed to advise her that the quality of the response we get is determined by the standard of the actual question we ask. Nobody cares about issues - folks just worry about solutions. Rather than continue asking “What’s the issue ? Why aren’t I getting pregnant ?”, she need to preferably be asking , “What can I do in order to get pregnant ?”

Ask a better question , therefore you get a far better answer ! It was an entirely new perspective for her, and I had to walk her through this viewpoint. As I told her, it barely mattered what are the reasons for her inability to conceive had been - the only thing which mattered was how all of us can fix the problem.

Everybody knows: GIGO - garbage in, garbage out. In case you continue asking “What’s the problem ?” you will end up throwing away a lot of time, money and energy in trying to discover it. Sadly, several of these diagnostic labels are incorrect, unreliable or simply completely wrong. For instance, a couple of years ago, numerous patients had been identified as having an “inadequate luteal phase” - and perhaps treated for this issue ! We now realize, with hindsight, that there's absolutely no such situation, and we did a significant disservice to our patients by coining this term and doing such a (mis)diagnosis.

This breaks my heart when I notice how much time and money infertile folks have lost in seeking a diagnosis. Is it the endo , doc ? Could I be possessing antisperm antibodies ? These are all the completely wrong concerns, but we see this all the time.

Hence, after a unsuccessful IVF cycle , the first question patients ask is - Why didn’t I get pregnant ? (Interestingly, patients who conceive after IVF (In Vitro Fertilization) never ask - Why did I get pregnant? The truth is that we can't answer either of these questions - and quite often it’s only a matter of chance!

The correct question patients should be asking after a unsuccessful IVF cycle is - What can I do next? Usually, the best solution would be to repeat the IVF (In Vitro Fertilization) cycle. It’s a lot like purchasing a lottery ticket - there’s absolutely no compulsion to do so, but if you don’t buy, you don’t win! And the oftener you purchase, the greater your chances of winning!

That's why, for many infertile patients, it’s better to look ahead instead of to look backwards. The best question is - What’s the next thing? Its best if you make a list of all feasible treatment alternatives - ranging from: stopping treatment and remaining child-free; adopting; repeating the IVF cycle; doing the IVF cycle at a new medical center; or utilizing third party reproduction. After that you can eliminate the alternatives that you will not consider, so that you are then left with the alternatives you are ready to explore. After this you ought to concentrate on each one of these, until you discover one which is best for you.

Usually, if you are using this technique, you might find that the absence of alternatives makes decision making easy , and you can prepare your next step and navigate your path through the infertility maze with much less effort !

Wednesday, December 22, 2010

Like all professionals, doctors have a certain image about themselves . Similarly, patients have expectations of their doctors and expect them to conform to their mental model of how a doctor should behave.

Life was much easier in the past when both patients and doctors expected doctors to behave as demi-Gods. The doctor was a shaman who was considered to be a healer who had been inspired by divine powers which he could use to help the sick to get better.

In modern society, however, things have changed considerably; and few patients will treat their doctors as God-like figures ( and I feel most doctors would also be very uncomfortable in this role !)

What roles do doctors adopt today ? These are primarily three, as articulated so well by the British economist, Julian Le Grand. We perceive doctors act as:Knights ( when their major driving force is virtue); Knaves ( when driven by rigid self-interest ; or asPawns ( when they feel they are just passive victims of their circumstances.

All doctors play all three roles at various times in their life – but your primary avatar will depend upon your life experiences and your self esteem. We are Knights as we care for our patients. Always acting in the best interest of our patients is our primary professional role, and society holds us in high esteem for that. However, many healthcare activists take perverse pleasure in painting doctors as being self-interested and greedy; and paint all doctors as having Knave-like qualities ( an unflattering image some doctors help to reinforce when their primary focus seems to be on grabbing money ). Finally, in this day and age of insurance paperwork and governmental regulation , many doctors have simply given up and play the role of a bitter passive victim who is overwhelmed by demanding patients and squeezed by corporate hospitals. However, society is not kind to Pawns !

If we as doctors want society to regard us with the respect which we feel is our due, we should be aware of societal perceptions and foster a regard of doctors as Knights, and not as either roguish Knaves or helpless Pawns. Remember that society will treat us the way we expect to be treated and we will get what we deserve !

So how do you behave as a Knight and get your patients to trust you ? By proving that you deserve their trust – and you need to earn this, by being generous with your knowledge; showing your patients that you care; respecting their time; and fulfilling your promises. The hallmark of doctors who have been elevated to the status of being treated as trusted advisors by their patients is that the doctor places a higher value on maintaining and preserving the doctor-patient relationship itself , rather than on the outcome of the current consultation.

Establishing a history of reliability is one way to build trust. For example, if you tell the patient you're going to call with lab results, make certain that you do just that. Doing this the first time will show your patients that they can count on you. Doing it again and again will build trust. To win your patient’s trust, you have to behave as a professional – someone who will place the patient’s interests before his own – so that both of you benefit in the long run ! This is why senior doctors valued their reputation so much – it was built on the foundation of a lifetime of hard work – and even though it is intangible, it represents the fact that patients have trust in you.

Credibility = can your patient trust what you say ?Reliability = can he trust your actions, confident that you will act honorably ?Intimacy = is he comfortable discussing his feelings and emotions with you ?Self-orientation = can he trust your motives, knowing that you care about him, and will act in his best interests ?

Professionalism is one of our core competencies , and we need to encourage all doctors to behave as Knights in the care of patients. Being a physician is still one of the greatest privileges society offers anyone, and we should always remember how fortunate we are.

Tuesday, December 21, 2010

My daughter has not been well for the last 14 days. She’s been running a fever of about 100- 102 F – and this has been worrisome as a parent. As a doctor , I have learnt quite a bit about how healthcare works ( and does not). What have the lessons been ?

As with all illnesses, we hoped that the fever would be self – limited and would settle down on its own. We therefore treated it symptomatically, with masterly inactivity. My wife is now blaming herself for not doing anything for 4 days. However, I think this was the right decision. If we start treating every fever, then we’ll end up wasting time and money on overtesting and overtreatment. Fortunately, the body has quite a bit of its own wisdom and most problems are self-limited. Of course, we have no way of knowing in advance which fever is going to break on its own; and which one is going to be persistent, so there’s no point in beating up on yourself in hindsight. This again re-emphasises the role of the family as the primary medical care giver !

Since both my wife and I are doctors, we tend to be quite conservative and not over-react. However, when the fever persisted for more than 3 days then we did what every good patient should do – we consulted our family physician. We did the basic tests – and these all turned out to be normal, so we started empiric treatment with antimalarials and antibiotics. The fever broke, so we were all relieved – but then it came back again, so we needed to escalate.

This is when we realized how limited our diagnostic tools are ; and how difficult it is to make a diagnosis of such a common problem ! “ Fever panels “ ( a series of tests which labs provide) are fine if they are positive, but a negative test means nothing. Thus, she could have malaria, and we cannot rule this out just because the smear test is negative. This can be very frustrating – for both doctors and patients.

We took her to an internist, who did a marvelous job. He took a concise history; summarised the story of her fever in 3 lines; explained his plan of action; told my daughter what to do and what to expect; and reassured us. In about 15 min, he had completed his examination and assessment . His working diagnosis was made and we needed to run some more tests to confirm this. He selected an appropriate antibiotic and explained why he had chosen which one he did. He was an excellent clinician , and we were very happy with him ! ( However, even though he is an academic physician, I did notice that he did not have an electronic medical record. This means that he really has no way of critically analyzing the records of all the outpatients he has seen over the last 20 years of his practice , so that all his wisdom will remain clinical judgment, but will not be rigorously documented. )

As it turned out, coming to a diagnosis was surprisingly important. This label gives you a handle around which you can organize your thinking. Are we on the right track ? Are we missing anything ? How long will she take to get better ? What’s the prognosis ? Will this affect her studies? Even if the diagnosis may not be correct , it still provides a useful tangible end point around which medical care can be organized.

The internet was a bit of a disappointment because there was very little information on the management of fevers in India. This is a shame , because this is such a common problem , and there are so many worried patients looking for information. While there is a lot of information on typhoid fever and the antibiotics used for its treatment, not much of this is India-specific, so that one has to keep on reading between the lines . Why haven’t Indian doctors taken a more proactive role on educating their patients online ?

I do hope a clever young doctor will provide this very useful service. It could be a very simple guide for patients but would hold their hand and walk them through their next steps. When to worry; When not to; What tests to do and when; When to get a medical consultation; When to panic

Medicine still remains a combination of science and art – clever doctors use a mix of both to help their patients to get better !

Lies, Damned Lies, and Medical Science - Magazine - The Atlantic: "He and his team have shown, again and again, and in many different ways, that much of what biomedical researchers conclude in published studies—conclusions that doctors keep in mind when they prescribe antibiotics or blood-pressure medication, or when they advise us to consume more fiber or less meat, or when they recommend surgery for heart disease or back pain—is misleading, exaggerated, and often flat-out wrong. He charges that as much as 90 percent of the published medical information that doctors rely on is flawed.

Let the reader beware ! Trust your own common sense - not the latest flavour of the month - whether it's being peddled by your doctor or by your newspaper !

Monday, December 20, 2010

One of the reasons my blog has been a little neglected lately is that I have been trying to learn Sanskrit. Learning a new language is hard work – especially for someone like me, who has poor aural skills ! What have a learnt during this journey ?

The key is to find a good teacher, and I have been very fortunate in finding a superb guru ! This is Mr Sudhir Kaicker who teaches Sanskrit out of the love of his heart – and keeps me going when I falter or feel that I am never going to make any progress ! He never criticizes and is extremely patient and supportive. He’s taught me a lot – and not just Sanskrit, but how to help others to learn !

However, the surprising lesson for me was the discovery that I learn a lot from other students ! We are all in the same boat – and while struggling to swim, we end up teaching each other quite a bit. The other student with me is Mr Ravi Gogte, who is far more advanced than I am, so it’s very helpful to have someone I can ask for help when I am stuck !

To teach optimally, teachers should organize students in small groups ( of 2 or 3) so they can help each other to progress. The best way to learn is by teaching someone else – and it’s much easier to learn from your peers, as the problems you encounter are very similar and you are on the same wavelength. Also, a little bit of friendly competition helps to keep you on your toes.I also find that it takes me a long time to learn a new concept – and it’s much easier for me to understand this when it is presented to me in many different formats ( until it finally sinks in !) This is why I have bought a lot of books; and study from all of these in parallel. Each book has strengths and weaknesses – and by using them together, I can learn more efficiently.

Incidentally, all my Sanskrit classes have been online on Skype. Using a blended model of online learning with books helps me quite a bit – and there are a not a lot of clever online resources I enjoy exploring. I especially like the Sanskrit Ipad app called Sanskrit primer.

So why am I learning Sanskrit now ? Good question – and one I’ll answer later !

Saturday, December 18, 2010

The BMJ editorial in the Christmas issue takes a light hearted look at the issue of information overload for doctors, and how this affects their practice and their relationships with their patients.

The author, Richard Smith suggests a number of coping strategies including the ostrich strategy (ignore all new information), the pigeon strategy (hang around other doctors and pick up bits of information) and the inhuman strategy (create a machine to help you).

I can think of some more birds ! For example, the vulture strategy ( voraciously devour all information , but be very undiscriminating ) ; and the mother bird strategy ( regurgitate everything you swallow, without processing it).

Saturday, December 11, 2010

We live in the US and I was diagnosed with Polycystic Ovarian Syndrome in 2003. We had been to an obgyn in the US and she had recommended 3 cycles of clomid treatment. Since this did not work for us, she had asked us to go for higher infertility treatments like Artificial Insemination or IVF. At that point we did not have proper information regarding these treatments and hence were not mentally prepared to proceed further.

Later we started research on the Internet regarding various infertility treatment options for us. It was at this time that we came across this amazing website. Dr.Malpani's website is an excellent source of information for infertility related issues. This was a panacea for all our questions. We then started interacting with Dr.Malpani through his website. We submitted the second opinion form with all the relevant information. Dr.Malpani graciously replied to all our queries. He was very prompt and patient with our questions. After 2 months of interaction with him, we finally decided that we should travel to Mumbai to start our infertility treatment at the Malpani clinic.

We stay at Hyderabad. However, Dr. Malpani was very flexible and had given us a treatment plan in advance so that we can plan out our trip and stay in Mumbai. We stayed at the accomodation at Janaki Nursing home. It was very cost effective and homely.

Our treatment started on Jan 7th 2010. We were advised to undergo IVF treatment. The IVF comic book on the website was very helpful to understand the various steps in the IVF treatment. On our first visit we were very impressed. There was not much waiting time. It was well organized and the staff was very friendly.

Dr.Mr& Mrs Aniruddha Malpani are well experienced and knowledgeable couple. Our treatment went exactly as planned per the steps in the IVF calendar on the website. It was on Jan 21st that 3 embryos were implanted. I requested for anesthesia during implantation since I was nervous. We were asked to see the embryos first. The embryologist walked us through the process of development before the implantation.

Later after 2 days of rest, we flew back to Hyderabad. I took a week's rest at home and flew to the US on Jan30 th. On Feb 4th, I did a home pregnancy test and by god's grace and Dr.Malpani's guidance and support I was pregnant. We were blessed with a healthy baby boy on Oct 1st 2010. What we once thought was very difficult turned out to be so easy at the Malpani clinic.

Thursday, December 09, 2010

I sometimes cringe when I see what advise some patients get from their doctors.

" I am 24 years and my wife is 22 years old .I got married one and half years and we are trying last one year for baby, but couldn't succeed. I tested myself and got the report that my sperm count is 95million /ml but my motility is 60%. Doctor said "your motility is low" and started treatment of last six months."

The trouble is that he's much more likely to trust his real life doctor whom he can see face to face, as compared to an email from someone he does not know ( even though my advise is much better than the advise he's getting from his doctor).

The doctor's ignorance is appalling - or is he just trying to make a quick buck ?

I guess the saving grace is that at least the patient had the sense to counter-check the advise his doctor was giving him - sadly, this is something which very few patients take the trouble to do !

At the Dr Batra Positive Health Awards held recently in Mumbai, Mr Rajv Bajaj, CEO of Bajaj Auto commented that he had learnt a lot about managing his very successful company by studying homeopathy. I was very intrigued and requested him to elaborate.

This is the email he sent me, which I’d like to share. These are very original ideas which can provide a lot of food for thought !

“ 1. Ideation: Individualisation & brands.

One of the fundamental principles of homoeopathy is individualisation. We are not what we have in common, but what we have in uncommon with others.

In disease terms, it’s our strange, rare, & peculiar symptoms that make us the unique individuals that we are. The good homoeopath seeks to glean that & then choose the one remedy that's that individual's similimum.

In a similar vein, a business that is like its competitors ie is not unique is essentially a commoditised business.

Most of us make this mistake either out of a greed for growth and/or a false sense of security in ill-conceived derisking.

So we try to make everything to sell to every market/segment/individual.

The result is that in the end, directly or indirectly, the business competes on price, as every competitor is making the same claims.

Are they not ill? And in subsidising them, our governments make us ill!

On the other hand the individualised automakers ie specialists , who handle brands such as Porsche , Mercedes , BMW, Harley ( and Bajaj !) are far more profitable ie healthier.

That's not to suggest that individualisation means being a premium niche player.

There's nothing premium about Swatch , Coke or Mcdonalds but they're are well because they all stand for a uniqueness.

There are many lessons in homoeopathy's concept of individualisation that can help guide brand strategies.

2. Execution: posology ( the science of doses) & execution.

Once the homoeopath has chosen a suitable remedy, how he gives it to the patient (the posology ) is not mechanical as it is in allopathy, but is rather artistic as it too is individualised.

In the same way, how ideas relevant to one brand are executed in one company may not only be unsuitable, but may even be inimical to another company.

Yet under the broad (but shallow) argument of benchmarking management consultants will tell us that one of the best things that we can do is to adopt someone else's best practises!

A homoeopath's posology is guided by 4 fundamental principles-

* Simila similibis curantur – “ like cures like :. An immune system's response can be galvanised against a problem by magnifying the problem before it.

* Use a single remedy . If more than one remedy is administered at a time, how does one know what effects are related to which causes?

* Use the smallest dose . If the remedy is resonant it will work gently as it shouldn't need a big dose to get the job done.

* Use potentised repetition . Every time the remedy is repeated , its potency should be slightly altered so that it creates a somewhat new sensation each time.

If you reflect upon these , you will see how they can help managers execute their business ideas better. These are just 2 examples, & I must warn you that they are my personal interpretations as a homoequack! “

As a doctor, I am big believer in Integrative Medicine. I do not think any branch of medicine has a monopoly on knowledge and we should all be willing to learn from each other. What ever works for the patient is what’s best ! I think we can all learn from each other – and most of the “fun stuff” happens at the cutting edge/ boundary of 2 apparently unrelated fields.

I especially like Rajiv’s key hypothesis - that you should play to your strengths !

It's a good idea to ask yourself - What unrelated fields have you learnt from ? And what have you learnt from them ? Please share !

Monday, December 06, 2010

Researchers looked at adult visits to seven primary care practices in North Carolina during 2008. They asked patients about their perceptions of medical mistakes and how did it influence the choice to switch doctors.

But anecdotes cited by patients as mistakes were often normal diagnostic or therapeutic challenges. A typical scenario might be the patient reported symptoms, the doctor did not correctly diagnose it at first presentation, and a specialist or second physician offered a specific diagnosis. Other scenarios included medication trials or side effects from the prescription.

If you are not happy with your doctor ( or his staff), please speak up ! You have invested time , energy and money on your relationship - why throw it all away without giving him a chance to fix the problem if you are not happy ? If patients do not provide feedback, how will doctors improve ?

When patients are aware of such things as their weight, BMI, blood pressure, recent key laboratory results, and so on, and when they come to the office motivated and prepared, outcomes are likely to be much better. The patient who passively waits for advice and direction from the physician is more likely to forget instructions, make excuses for failures, lack the discipline to lose the needed weight or stay on the required diet, and so forth.

Patients themselves, not their doctors, must be the ones to make the essential decisions about their health. They must be able to obtain the necessary information to make key decisions, then act on them.

After 6 years of unsuccessful treatments in Bangalore, we had decided that we were not going for another IVF cycle. I’d been diagnosed with PCOD and one blocked fallopian tube because of which I had two ectopic pregnancies. A friend’s uncle who was a renowned doctor in Bangalore suggested we meet up with Dr Malpani in Mumbai. After getting over our initial ‘If’s and ‘How’s on how to manage treatment in Mumbai since we are based out of Bangalore, we wrote to Dr Malpani. The prompt reply put us right at ease. We fixed a date, met Dr Malpani in Mumbai and decided to go ahead with one last IVF attempt. We went through the initial 9 days of shots in Bangalore. All through the months after we met Dr Malpani, his website and the success stories on the site were a huge confidence booster. The 10th day we reached Mumbai and were told that as my 10th day scan did not show many follicles, my chance of obtaining mature eggs were not good. Dr Anjali asked me to change the shots that I was taking till then. I was put on a new set of shots and the follicles immediately started showing good results. The embryo transfer took place and we flew back to Bangalore. Contrary to what was told to us earlier, Dr Malpani advised us to lead a normal life and get back to work. This helped in putting us at ease tremendously. 14 days later, we got a positive result on our Beta-HCG! The count kept rising every couple of days and 9 months later we are proud parents to a beautiful baby girl ! Dr Malpani’s clinic not only has the best doctors, but the attention from every single member of the staff is extremely touching and endearing. We look back to the clinic with such fond memories. We have a couple of our friends with infertility issues already meeting with Dr Malpani and we are sure of them conceiving soon as well. Prayers and our heartfelt wishes to Drs Aniruddha ,Anjali Malpani and their team.